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Volume 1 | Issue 2
www.TheJopa.org
Jopa
Journal of Orthopedics
for Physician Assistants
Review Articles
Meniscal Tears: Repair or Resect?
Direct Anterior Approach Total Hip Arthroplasty
Case Studies
Cervical Total Disc Replacement
Common Meniscal Tears
Anatomy and Image Review
with a Surgical Perspective
The First
Orthopedic Journal
for Physician Assistants
JOPA 1
Journal of
Orthopedics for Physcian Assistants
Journal Mission
The Journal of Orthopedics for Physician
Assistants (JOPA) is an academic resource created to
deliver ongoing orthopedic education for physician
assistants. The journal is a unique forum to share
our knowledge and experiences with colleagues in
the profession. JOPA strives to publish timely and
practical articles covering all subspecialties. Each
article is peer reviewed to ensure accuracy, clinical
relevance, and readability.
Contents
4
6
Information for Authors
7
11
Physician Assistant
Review Board
2
JOPA
Jennifer Hartman
Peoria, AZ
Michael Harvey
Fishers, IN
Sean Hazzard
Boston, MA
Matt Henry
Rapid City, SD
Tim Holmstrom
Pullman, WA
Mike Houle
Hartford, CT
Alan Johnston
Nashua, NH
Stuart Jones
Brentwood, TN
Jason Katz
Philadelphia, PA
Jill Knight
Seattle, WA
Stanley Kotara
Lubbock, TX
Kathleen Martinelli
Durham, NC
Sean Metz
Buffalo, VA
Patrick McCarthy
Manchester, NH
Terry Mize
Atlanta, Georgia
Randall Pape
USAF Academy, CO
Keith Paul
Greensboro, NC
Robert Rogan
Poughkeepsie, NY
Scott Walton
Caribou, ME
Todd Rudy
Wellsboro, PA
Bradford Salzmann
Ware, MA
Jeffrey Sommers
Marietta, OH
Steve Steiner
Manchester, NH
Wendi Martin
Stewart
Houston, TX
Lori Tappen
Dallas, TX
Timothy Thompson
Naples, FL
Mary Vacala
Savannah, GA
Courtney Van
Arsdale
Boston, MA
Marcos Vargas
Flushing, MI
Common Meniscal Tears
Anatomy and Image Review
21
22
26
NCCPA Orthopedic CAQ Sample
Exam Question
Of Powder Plaster, Overhead
Traction, and Broomstick
Prosthesis
Direct Anterior Approach THA
A comparative review of surgical approaches to
the hip
33
Marlon Alexander
Rosharon, TX
Brian Barry
Portsmouth, NH
Ryan Brainard
Savannah, GA
Afton Branton
Geneva, NY
Molly Buerk
Aurora, CO
Mark Carbo
Alexandria, LA
Ray Carlson
San Diego, CA
Jeff Chambers
Athens, Georgia
Larry Collins
Tampa, FL
Greg DeConciliis
Boston, MA
Charles Dowell
Vancouver, WA
Caitlyn Eagen
Boston, MA
Erich Fogg
York, ME
Bruce Gallio
Reno, NV
Angela Grochowski
Horsham, PA
Cervical Total Disc Replacement
Meniscus Tears
Repair or Resct
16
Dagan Cloutier, PA-C, Editor in Chief
Ryan Ouellette, Webmaster, thejopa.org
Spectrum Marketing, Journal Design
Orthopedic Publishing Resources, LLC, Publisher
Message from the Editor
Writing for JOPA
Message from the NCCPA
Orthopedic CAQ Exam
Disclaimer: Statements and opinions expressed in articles
are those of the authors and do not necessarily reflect those
of the publisher. The publisher disclaims any responsibility
or liability for any material published herein. Acceptance of
advertising does not imply the publisher guarantees,
warrants, or endorses any product or service.
Message from the Editor
Publishing the first issue of JOPA was a challenging yet rewarding experience. My efforts have been
rewarded by hearing the positive responses from many of you. Several have expressed interest in writing
and peer reviewing, while others have emailed me with appreciation for creating the only orthopedic journal
dedicated to PAs. JOPA proudly provides an orthopedic focused educational resource and professional forum
for PAs at no cost. The steady growth of subscribers is an encouraging sign that PAs appreciate the value of
an orthopedic focused journal for our profession.
Being editor in chief of JOPA has motivated me to continually read and
learn more about orthopedics. The experience has also made me realize
how much more I can still learn. I hope the journal will also be a motivator
for all of you to read, write, and continually learn. Our dedication to reach
and maintain a high level of orthopedic knowledge correlates with the
quality of patient care we deliver. As PAs, the privilege of making patient
care decisions independently is earned by confidently and accurately
treating patients. Our supervising physicians, clinical staff, and patients all
recognize and appreciate the level of orthopedic knowledge we possess.
JOPA will continue to promote a comprehensive orthopedic review
across all subspecialties. Please consider getting involved by sharing
your knowledge and experiences with your colleagues. The quality and
Dagan Cloutier, PA-C
JOPA Editor in Chief
sustainability of JOPA will be a collective effort.
Join the JOPA Editorial Board
All articles submitted to JOPA are reviewed
by the Editor in Chief, who is responsible for
deciding whether an article is accepted, rejected,
or in need of revision before publication. JOPA
will be forming an editorial board by subspecialty.
Each subspecialty section will be represented
by a physician assistant or section editor whose
knowledge and experience lies within the chosen
subspecialty. Each section editor will review
submitted articles within their subspecialty prior
to publication and send articles to a group of peer
reviewers who share knowledge and experience in
the subspecialty. Once peer reviewed, authors will
have the opportunity to revise their article and
re-submit for publication. This will ensure that all
articles published in JOPA are accurate, clinically
relevant, and readable. Anyone interested in joining
the editorial board should email, Dagan Cloutier,
Editor in Chief, at dcloutier@thejopa.org.
Subspeciality
Sections
•
•
•
•
•
•
•
•
Hand
Spine
Trauma
Arthroplasty
Sports
Foot and Ankle
Pediatrics
Tumor
JOPA 3
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IMPORTANT SAFETY INFORMATION
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events.
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QBJOPSTXFMMJOHPGUIFJOKFDUFEKPJOUNBZPDDVSBGUFSJOUSBBSUJDVMBS
JOKFDUJPOXJUI&6'-&99"
EUFLEXXA®JTBSFHJTUFSFEUSBEFNBSLPG'FSSJOH#7
©2013 Ferring Pharmaceuticals Inc.
4
JOPA
01/13
EUF-C21717
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SFQPSUFEJOBOEXFFLDMJOJDBMTUVEJFTXFSFBSUISBMHJBCBDL
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References: 1.,JSDIOFS..BSTIBMM%"EPVCMFCMJOESBOEPNJ[FEDPOUSPMMFEUSJBMDPNQBSJOH
BMUFSOBUFGPSNTPGIJHINPMFDVMBSXFJHIUIZBMVSPOBOGPSUIFUSFBUNFOUPGPTUFPBSUISJUJTPGUIF
LOFFOsteoarthritis Cartilage2.&6'-&99"<QBDLBHFJOTFSU>1BSTJQQBOZ
/+'FSSJOH1IBSNBDFVUJDBMT*OD
Please see brief summary of Prescribing Information
on the next page.
BRIEF SUMMARY
Please consult package insert for full Prescribing Information.
CONTRAINDICATIONS
Do not use EUFLEXXA to treat patients who have a known hypersensitivity to hyaluronan preparations; Do not use
EUFLEXXA to treat patients with knee joint infections, infections or skin disease in the area of the injection site.
WARNINGS
Mixing of quaternary ammonium salts such as benzalkonium chloride with hyaluronan solutions results in
formation of a precipitate. EUFLEXXA should not be administered through a needle previously used with medical
solutions containing benzalkonium chloride. Do not use disinfectants for skin preparation that contain quaternary
ammonium salts; Do not inject intravascularly because intravascular injection may cause systemic adverse events.
PRECAUTIONS
GENERAL
Patients having repeated exposure to EUFLEXXA have the potential for an immune response; however, this has not
been assessed in humans; Safety and effectiveness of injection in conjunction with other intra-articular injectables,
or into joints other than the knee has not been established; Remove any joint effusion before injecting; Transient pain
or swelling of the injected joint may occur after intra-articular injection with EUFLEXXA; Do not use after expiration
date; Protect from light; Do not re-use—dispose of the syringe after use; Do not use if the blister package is opened
or damaged.
Information for Patients
Provide patients with a copy of the Patient Information prior to use; Transient pain and/or swelling of the
injected joint may occur after intra-articular injection of EUFLEXXA; As with any invasive joint procedure, it is
recommended that the patient avoid any strenuous activities or prolonged (i.e., more than 1 hour) weight-bearing
activities such as jogging or tennis within 48 hours following intra-articular injection; The safety of repeated
treatment cycles of EUFLEXXA has been established up to 1 year.
Use in Specific Populations
Pregnancy: The safety and effectiveness of EUFLEXXA have not been established in pregnant women.
Nursing Mothers: It is not known if EUFLEXXA is excreted in human milk. The safety and effectiveness of EUFLEXXA
have not been established in lactating women. Children: The safety and effectiveness of EUFLEXXA have not been
demonstrated in children.
ADVERSE REACTIONS
Adverse event information regarding the use of EUFLEXXA as a treatment for pain in OA of the knee was available
from two sources; a 12 week multicenter clinical trial conducted in Germany, and a 26 week multicenter clinical trial
conducted in the US.
Reported Device-Related Adverse Events
The most common adverse event related to EUFLEXXA injections reported in the clinical studies are the
following: Arthralgia; Back pain; Pain in extremity; Musculoskeletal pain; Joint swelling. All adverse events related
to EUFLEXXA injections reported in Tables 1, 2, 3 and 4.
Potential Adverse Events
The following adverse events are among those that may occur in association with intra-articular injections:
Arthralgia; Joint swelling; Joint effusion; Injection site pain; Arthritis
12 Week Multicenter Clinical Study
This clinical investigation was a prospective randomized, double-blinded, active control (commercially available
hyaluronan product) study conducted at 10 centers. Three hundred twenty-one patients were randomized into
groups of equal size to receive either EUFLEXXA (n=160) or the active control (n=161).
A total of 119 patients reported 196 adverse events; this number represents 54 (33.8%) of the EUFLEXXA group
and 65 (44.4%) of the active control group. There were no deaths reported during the study. Incidences of each event
were similar for both groups, except for knee joint effusion, which was reported by 9 patients in the active control
group and one patient in the EUFLEXXA treatment group. Fifty-two adverse events were considered device-related.
Table 1 lists the adverse events reported during this investigation.
Table 1. Incidence of Adverse Events Reported by >1% of Patients
Patients, n (%)
Body System
ADE
EUFLEXXA
Active Control
(n = 160)
(n = 161)
Gastrointestinal
Nausea
3 (1.88)
0
disorders
General disorders and
Fatigue
2 (1.25)
0
administration site
Infections and
Bronchitis
1 (0.63)
2 (1.24)
infestations
Infection
2 (1.25)
0
Investigations
Blood pressure
6 (3.75)
1 (0.62)
increased
Arthralgia
14 (8.75)
17 (10.6)
Arthrosis
2 (1.25)
0
Musculoskeletal,
Back pain
8 (5.00)
11 (6.83)
connective tissue
Joint disorder
2 (1.25)
2 (1.24)
and bone
Joint effusion
1 (0.63)
13 (8.07)
Joint swelling
3 (1.88)
3 (1.86)
Pain in limb
2 (1.25)
0
Tendonitis
3 (1.88)
2 (1.24)
Nervous system
Headache
1 (0.63)
3 (1.86)
disorders
Paresthesia
2 (1.25)
1 (0.62)
Respiratory, thoracic
Rhinitis
5 (3.13)
7 (4.35)
and mediastinal
Skin and subcutaneous
Erythema
0
2 (1.24)
tissue disorders
Pruritus
0
3 (1.86)
Vascular disorders
Phlebitis
0
2 (1.24) .
A total of 160 patients received 478 injections of EUFLEXXA. There were 27 reported adverse events
considered to be related to EUFLEXXA injections: arthralgia – 11 (6.9%); back pain – 1 (0.63%); blood
pressure increase – 3 (1.88%); joint effusion – 1 (0.63%); joint swelling – 3 (1.88%); nausea – 1 (0.63%);
paresthesia – 2 (1.25%); feeling of sickness of injection – 3 (1.88%); skin irritation – 1 (0.63%); tenderness
in study knee – 1 (0.63%). Four adverse events were reported for the EUFLEXXA group that the relationship to
treatment was considered to be unknown: fatigue – 3 (1.88%); nausea – 1 (0.63%).
Table 2. Relationship of Adverse Effects to Treatment Groups That Were Considered to Be Treatment Related
(EUFLEXXA)
Commercially Available
Hyaluronan Product
Adverse Event
(Number of Reports)
(Number of Reports)
n = 160
n = 161
Arthralgia
11
9
Back pain
1
0
Baker’s cyst
0
1
Blood pressure increase
3
0
Erythema
0
1
Inflammation localized
0
1
Joint effusion
1
9
Joint swelling
3
2
Nausea
1
0
Edema lower limb
0
1
Paresthesia
2
0
Pruritus
0
1
Sickness
3
0
Skin irritation
1
0
Tenderness
1
0
TOTAL
27
25
©2013 Ferring Pharmaceuticals Inc.
26 Week Multicenter Study
This was a multicenter, randomized, double-blind trial evaluating the efficacy and safety of EUFLEXXA, as compared
with saline, in subjects with chronic osteoarthritis of the knee followed by an open labeled safety extension study.
The intervention consisted of three (3) weekly injections of study device into the target knee, with scheduled
follow-up evaluations during the 26 weeks following the first injection. In the extension phase subjects received three
(3) weekly injections of EUFLEXXA into the target knee with follow-up evaluation up to 52 weeks. Table 3 shows the
treatment-emergent adverse events by preferred term with an incidence of ≥ 2% among treatment groups.
Table 3: Treatment-Emergent Adverse Events (TEAEs) by Preferred Term with an Incidence of > 2% among the
Treatment Groups (Safety Population)
Extension
Study Repeat
Injection for
26 Week FLEXX Study (Core)
52 Weeks*
All Treatments
Saline
EUFLEXXA
EUFLEXXA
System Organ Class
N = 588
N = 295
N = 293
N = 219
Preferred Term
n (%)
n (%)
n (%)
n (%)
Any TEAE
326 (55.4)
169 (57.3)
157 (53.6)
96 (43.8)
Musculoskeletal and connective tissue disorders
Arthralgia
62 (10.5)
35 (11.9)
27 (9.2)
19 (8.7)
Back pain
23 (3.9)
11 (3.7)
12 (4.1)
6 (2.7)
Pain in extremity
13 (2.2)
10 (3.4)
3 (1.0)
3 (1.4)
Musculoskeletal pain
10 (1.7)
4 (1.4)
6 (2.0)
2 (0.9)
Osteoarthritis
9 (1.5)
7 (2.4)
2 (0.7)
0
Joint swelling
8 (1.4)
4 (1.4)
4 (1.4)
6 (2.7)
Infections and infestations
Upper respiratory
23 (3.9)
11 (3.7)
12 (4.1)
6 (2.7)
tract infection
Nasopharyngitis
17 (2.9)
13 (4.4)
4 (1.4)
10 (4.6)
Sinusitis
16 (2.7)
10 (3.4)
6 (2.0)
5 (2.3)
Urinary tract infection
12 (2.0)
6 (2.0)
6 (2.0)
3 (1.4)
Injury, poisoning, and procedural complications
Injury
17 (2.9)
9 (3.1)
8 (2.7)
9 (4.1)
Nervous system disorders
Headache
17 (2.9)
11 (3.7)
6 (2.0)
3 (1.4)
Gastrointestinal disorders
Diarrhea
14 (2.4)
2 (0.7)
12 (4.1)
3 (1.4)
Nausea
12 (2.0)
7 (2.4)
5 (1.7)
4 (1.8)
Respiratory, thoracic, and mediastinal disorders
Cough
10 (1.7)
3 (1.0)
7 (2.4)
3 (1.4)
Vascular disorders
Hypertension
18 (3.1)
5 (1.7)
13 (4.4)
1 (0.5)
*Treatment group for repeat study are for subjects who received EUFLEXXA in both the core and extension
(219 out of 433).
N = number of subjects in a given treatment group for the population analyzed; n = number of subjects reporting
at least one adverse event within system organ class/preferred term; (%) = percentage of subjects based on N;
TEAE = treatment-emergent adverse event.
Note: An adverse event was counted as a TEAE if it was either not present at baseline (prior to the first dose of
double-blind study device) or present at baseline but increased in severity during the treatment period.
During the initial randomization/treatment phase, 326 (55.4%) subjects in the safety population experienced 742
TEAEs. The proportion of subjects reporting TEAEs was generally similar in the EUFLEXXA and saline groups (53.6%
and 57.3%, respectively). The most common preferred term of TEAE was arthralgia (10.5% of all subjects). Thirty
(5.1%) subjects experienced severe TEAEs, and the proportion with severe events was larger in the saline group
(6.4%) than the EUFLEXXA group (3.8%). Overall, 10.4% of subjects had TEAEs considered related to study device,
with comparable proportions in each treatment group (9.9% and 10.8% for EUFLEXXA and saline, respectively).
During the extension phase, 43.4% (188/433) of subjects reported 377 TEAEs. Of these 43.8% (96/219) subjects
receiving repeated EUFLEXXAreported 199 TEAEs. The most frequently reported preferred term in subjects formerly
assigned to the core study EUFLEXXA group were arthralgia (8.7%), nasopharyngitis (4.6%), injury (4.1%), upper
respiratory tract infections (2.7%), joint swelling (2.7%), back pain (2.7%), and sinusitis (2.3%). Of these TEAEs 9
(4.1%) subjects had study device related AEs classified as “Certain,” “Probable,” “Possible” or “Un-assessable.” The
most common related TEAEs were arthralgia (2.3%) and joint swelling (1.4%). Table 4 shows the Study Device
Related Treatment-Emergent Adverse Events by Preferred Term with an Incidence of > 1 among Treatment Groups
(Safety Population).
Table 4: Study Device Related Treatment-Emergent Adverse Events by Preferred Term with an Incidence of
> 1 among Treatment Groups (Safety Population)
Extension
Study
Repeat
Injection
for
26 Week FLEXX Study (Core)
52 Weeks*
All Treatments
Saline
EUFLEXXA
EUFLEXXA
System Organ Class
N = 588
N = 295
N = 293
N = 219
Preferred Term
n (%)
n (%)
n (%)
n (%)
Any related TEAEs
61 (10.4)
32 (10.8)
29 (9.9)
9 (4.1)
Musculoskeletal and connective tissue disorders
Arthralgia
23 (3.9)
13 (4.4)
10 (3.4)
5 (2.3)
Joint swelling
3 (0.5)
2 (0.7)
1 (0.3)
3 (1.4)
Pain in extremity
3 (0.5)
3 (1)
0
0
Skin and subcutaneous tissue disorders
Erythema
5 (0.9)
3 (1)
2 (0.7)
0
*TEAEs are for subjects who received EUFLEXXA in both the core and extension (219 out of 433).
N = number of subjects in a given treatment group for the population analyzed; n = number of subjects reporting
at least 1 AE within system organ class/preferred term; (%) = percentage of subjects based on N; TEAE = treatmentemergent adverse event.
Note: Related AEs are AEs with study device relationship classified as “Certain,” “Probable,” “Possible” or
“Un-assessable.”
Twenty-three serious TEAEs were reported in 19 (3.2%) subjects during the study: 10 (3.4%) subjects in the
EUFLEXXA group and 9 (3.1%) subjects in the saline group. One of these events was considered related to the
study device (increased redness of the left knee joint in the EUFLEXXA group). Eight (1.4%) subjects had 9 TEAEs
leading to discontinuation: 3 (1.0%) subjects in the EUFLEXXA group and 5 (1.7%) subjects in the saline group.
Twelve (2.8%) subjects reported 20 serious TEAEs during the extension phase. Six of these subjects had received
EUFLEXXAduring the core study. None of the serious TEAEs was considered related to study device, and all resolved.
Two (0.5%) subjects had TEAEs leading to discontinuation from the study, one of whom received EUFLEXXA
during the core study; both subjects had events that were considered unrelated to study device.
Two subjects on saline experienced joint effusion. There were no reports of joint effusion among subjects
receiving EUFLEXXA during the core and extension phase.
Toll free number for providers and patients to call with questions:
1-(888)-FERRING (1-(888)-337-7464).
Or visit www.euflexxa.com.
MANUFACTURED FOR:
FERRING PHARMACEUTICALS INC.
PARSIPPANY, NJ 07054
MANUFACTURED BY:
Bio-Technology General (Israel) Ltd.
Be’er Tuvia, Kiryat Malachi 83104, Israel
6122-10 9/2011
EUFLEXXA® is a registered trademark of Ferring B.V.
1/13
EUF-08264
Writing for JOPA: Information for Authors
The Journal of Orthopedics for Physician Assistants (JOPA) is a
peer-reviewed publication that delivers a broad range of orthopedic
content across all subspecialties. Authors can contribute any original
article that promotes an orthopedic education for physician assistants
(several examples are listed below). JOPA avoids publishing original
research and industry-sponsored articles, as well as articles previously
published or being considered for publication in other journals. Articles
are peer reviewed by a panel of orthopedic physicians and PAs to ensure
accuracy, clinical relevance, and readability.
References should be cited using the AMA Manual of Style, 10th edition. References should be recent and
predominately drawn from peer reviewed journals. Textbook and website references should be avoided if possible.
Article content, including the manuscript body and any tables, should be submitted in Microsoft Word format to
facilitate editing. Please use a standard font, such as Times New Roman, and a 12-point font size. Use appropriate
headings and subheadings in feature articles to organize paragraphs. JOPA reserves the right to edit content for space
and/or grammar issues. Any images that accompany an article must be sent as separate downloadable files from the
manuscript text for publishing.
Featured Review Articles
Featured review articles should contain a comprehensive
review of literature on an orthopedic topic of choice.
These academic literature reviews should be heavily
referenced and may be co-authored. Subspecialists
should consider writing on topics in their fields of
expertise. Featured review length should be 4-8 pages.
When considering the appropriate length, keep in mind
the clinical significance and readability of content.
Review Articles
Review articles should be 3-4 pages on an orthopedic
topic of choice. Review articles should be selective and
include few references. Authors may review a clinical
condition, surgical procedure, or any other topic related
to orthopedics. Preceptors may consider co-authoring a
review article with a PA student interested in pursuing a
career in orthopedics.
Case Studies
Case studies choose a case and provide a complete
history of the clinical presentation, treatment, and
outcome. Radiographs and other imaging should
be included to follow the course of a diagnosis and
treatment. Several learning points should be included at
the end of the case study, with appropriate references.
Please remove all patient identification information prior
to submission.
Case Reviews and Image Quizzes
Case reviews present a unique case with several images
and a brief description of the presentation, diagnosis,
and treatment. Image quizzes include an image for
6
JOPA
readers to interpret. Answers should be provided, with
a brief explanation of the patient and correct diagnosis.
Do not include literature review or references for case
reviews or image quizzes.
Be Creative!
Consider submitting a description of how your practice
uses PAs or the relationship you have with your
supervising physicians. Consider writing on a patient’s
experience and how it could be of value to PA colleagues.
Write a detailed narrative of a typical day in your life as
a PA. Personal experiences can be some of the most
interesting and helpful articles for other PAs to read. If
you have any other submission ideas, please contact the
editor at dcloutier@thejopa.org.
Supervising Physicians and
Allied Health Professionals
Supervising physicians may submit articles on topics in
their subspecialty or issues related to the PA profession.
Physicians may also choose to write on a procedure or
service unique to their practice. Co-authoring an article
with a supervising physician is a great way to promote
the physician-PA relationship. Nurse Practitioners
practicing in orthopedics are encouraged to contribute,
and may receive a free copy of JOPA by contacting
the editor or subscribing online. Contributions from
other allied health professionals, such as physical
therapists and athletic trainers, give PAs an opportunity
to learn from those with whom we share patient care
responsibilities. Allied health professionals who wish
to contribute to JOPA can contact the editor, Dagan
Cloutier, at dcloutier@thejopa.org.
Cervical Total Disc Replacement
Vladimir A. Sinkov, MD
A 29-year-old, right hand-dominant female
presented to the office with a 3-year history of
pain and paraesthesia over the right deltoid area.
The patient also noted that her deltoid muscle
fatigued quickly. By the end of the day, the patient
found it difficult to use her right arm, especially
with overhead activities. She had no history of
trauma; however, her symptoms began when she
was performing military training, including heavy
lifting and running with equipment for 10–14 h
per day. The patient was initially diagnosed with
an intercostal strain. With time, the pain began to
travel to her right shoulder and the right side of
her neck with occasional paraesthesias down the
neck and into the shoulder. She was treated with
non-steroidal anti-inflammatories and multiple
bouts of physical therapy, which would provide
approximately 24–48 h of relief, although the pain
always returned thereafter.
The patient was later evaluated by an
orthopedist, who obtained an MRI showing a
right-sided C4–5 disc herniation. She was referred
to a pain management center for epidural
steroid injections. The first injection provided
approximately 5 days of relief before symptoms
returned. The second injection provided
approximately 3 days of relief. Each injection
provided approximately 50% relief of the pain,
and the patient continued to use pain medication
after the injections. The patient had multiple
subacromial injections as well, which did not
relieve any of the pain.
The patient was seen by a neurologist
and underwent nerve conduction studies, which
did not reveal any evidence of radiculopathy
or suprascapular nerve problems. The patient
denied any trouble with balance or bowel or
bladder control. At the time or presentation, she
was working full time as an active duty military
officer. The patient denied a history of smoking,
drinking, and illicit drug use.
Examination of the cervical spine
showed mild tenderness to palpation over the
right periscapular muscles. No cervical spine
tenderness was noted. A positive Spurling’s test
to the right and a negative L’hermitte’s test were
noted. The patient had full range of motion of
her neck with generalized pain in all directions.
She had 5/5 strength in all muscle groups of the
bilateral upper extremities, including the deltoids.
Sensation was intact to light touch throughout
the bilateral upper extremities in all dermatomes,
C5–8. A negative Hoffman’s test was noted
bilaterally. Brachioradialis and triceps reflexes
were 2+ bilaterally, and the biceps reflex was 1+
on the right and 2+ on the left. The patient had
palpable and equal radial pulses bilaterally, and
2+ deep tendon reflexes of the bilateral quads.
Antero-posterior (AP) and lateral
radiographs of the patient’s cervical spine
showed no significant deformity. There was mild
loss of disc height at C4–5 with focal straightening
of cervical lordosis, as shown in Figure 1. MRI of
the cervical spine revealed disc bulging at C4–5,
creating central as well as right foraminal stenosis
(Figures 2 and 3). There was no abnormal spinal
cord signal; however, the spinal cord was mildly
indented by the disc bulge at C4–5.
Figure 1. Lateral radiograph showing C4-5
disc narrowing and focal loss of lordosis.
JOPA 7
Figure 2. Saggital MRI showing C4-5 disc
herniation.
The patient’s predominant complaint
was radiculopathy over the C5 dermatome on
the right side caused by a right sided C4–5 disc
herniation. Although short-lived, the patient had
a good response to epidural steroid injections,
which confirmed that her symptoms were due to
radiculopathy. Nerve conduction studies were
negative, but do not always reveal radiculopathy.
The patient failed multiple non-operative options,
including several years of waiting, medications,
physical therapy, and injections. Her choice was
to either live with the symptoms or undergo a
surgical procedure. After a lengthy discussion,
the patient chose to proceed with cervical total
disc replacement.
Discussion
Intervertebral discs are composed of
the inner nucleus pulposus and outer anulus
fibrosus. The nucleus pulposus is very elastic
and serves to cushion axial loads. The anulus
fibrosus contains the nucleus and connects
the vertebral bodies. Just posterior to the disc
is the spinal cord centrally and nerve roots
posterolaterally. The anulus fibrosus may
become torn or weakened after a traumatic event
or due to degenerative process, and a portion of
the nucleus pulposus can protrude or herniate.
This would put pressure on the spinal cord and/
or nerve roots, and may cause clinical symptoms.
The most commonly affected disc is C5–6,
followed by C6–7 and C4–5. Cervical disc
8
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Figure 3. Axial MRI image at C4-5 showing
right foraminal narrowing resulting in C5
nerve compression.
herniations are most common in the fourth
decade of life, and men are at a slightly higher
risk than women. Factors that can precipitate
disc degeneration and subsequent herniation
include cigarette smoking, frequent heavy
lifting, prolonged driving, or operating vibrating
equipment.1 If the disc pushes on a specific
nerve root, this may produce symptoms of
radiculopathy, including neck pain, neck muscle
stiffness, specific dermatomal and myotomal
distribution of pain, numbness, paresthesias,
weakness, and diminished reflexes.
History and clinical exam provide an
accurate diagnosis in the majority of cases. A full
neurologic exam must be performed. Other causes
of arm pain and weakness must be ruled out.
The most common problems that may present as
possible cervical radiculopathy include brachial
plexopathy, carpal tunnel syndrome, cubital
tunnel syndrome, and rotator cuff pathology.
Imaging modalities include AP and lateral
radiographs to evaluate bony alignment, disc
height loss, and osteophyte formation. Flexion/
extension lateral radiographs may reveal
segmental instability. Computed tomography
(CT) scans give better bony details, especially
for evaluation of facet and uncovertebral joints.
Addition of a myelogram provides an outline of
the neural structures and may reveal cervical
stenosis. The best modality for evaluation of the
disc structure and nerve compression is MRI,
which provides excellent soft tissue visualization
without exposure to radiation or the need for
contrast injection. Nerve conduction studies may
be performed in difficult cases, but the results
must be interpreted carefully. Negative nerve
conduction studies do not rule out radiculopathy
in milder cases.
Most cervical disc herniations can
be managed successfully without surgical
intervention. Initial treatment includes nonsteroidal anti-inflammatory medications and
physical therapy. For more severe symptoms,
prednisone taper may be needed. If these
treatments fail, epidural corticosteroid injections
can be done and have been shown to be effective
in a vast majority of cases.2 The injected steroid is
a potent anti-inflammatory agent that lowers the
expression of inflammatory cytokines in the area
of stenosis. This in turn decreases swelling and
compression around the nerves and lowers the
transmission of pain signals though the nerves.
Alternative medicine treatments, including
chiropractic manipulations and acupuncture,
are also frequently performed. If pressure on
the nerves or spinal cord is significant, the
patient must be cautioned against chiropractic
manipulations. Several studies have shown
rare but catastrophic cases of permanent nerve
damage, paralysis, and death in patients with
severe spinal stenosis undergoing chiropractic
manipulations.3,4
When non-operative treatments fail over
a period of at least 6 weeks and symptoms are
still significant, or if there is evidence of severe
compression that is unlikely to be amenable to
non-operative interventions, surgery may be
needed. The basic premise of such an intervention
is to decompress the neural structures. In
addition, there may be a need for stabilization
or deformity correction. Traditional surgical
techniques include anterior or posterior
decompression with or without fusion.
The most common operative intervention
for cervical radiculopathy is anterior cervical
discectomy and fusion (ACDF). Because the most
common structure compressing the nerves or
spinal cord is a herniated or bulging disc, anterior
discectomy allows for direct decompression of the
spinal canal and foramina. Fusion is required to
regain stability and allows correction of deformity
and restoration of disc height between the spinal
segments. The procedure is very effective, with
success rates of approximately 80–90%.5,6
The drawback of the ACDF procedure is
that immobilization of one level transfers more
stress to the adjacent levels. Biomechanical
studies have shown higher intradicsal pressures
and ranges of motion at the levels next to the
fused one.7 Clinical studies have shown that this
leads to a faster rate of degeneration of those
discs that would be expected due to aging and
wear and tear.8 A well-known study by Hillbrand
and colleagues published in 1999 found that
the rate of the symptomatic adjacent segment
degeneration was approximately 2.9% per year, or
25.6% after 10 years. Two-thirds of these patients
required additional surgery, most commonly
additional fusion, for this problem.9
Cervical Total Disc Replacement
Due to the relatively high rate of additional
procedures after ACDF, extensive research has
been done to find alternative treatments for
cervical disc herniation causing radiculopathy
or myelopathy. Because the main problem with
ACDF is the lack of mobility at the operated
level, cervical disc replacement devices were
developed to maintain the disc space and
alignment while recreating normal motion of
the removed disc. Most of the devices available
today involve two implants attached to vertebral
endplates that articulate with each other through
a metal-on-plastic interface, similar to current
total joint replacement devices.
Cervical total disc replacements (CTDRs)
have been performed since 1999, with the latest
studies showing either equivalent or superior
results compared to ACDF.10 Five-year studies
show lower rates of repeat surgery compared
to fusion.11 Long-term outcome studies are still
pending to show whether overall rates of repeat
surgery for adjacent segment degeneration is
lower than after fusion surgeries.
A key issue that inhibits wide acceptance
of CTDR for cervical radiculopathy is the lack
of approval by insurance carriers. Despite
the fact that these devices are FDA-approved,
most private insurance carriers consider disc
replacement an experimental procedure. A
lengthy appeal process is usually required
to achieve insurance carrier approval for the
surgery.
Case Outcome
Our patient engaged in lengthy discussion
about treatment options. The patient had
degenerative disc disease and radiculopathy at
C4–5, causing neck and right arm pain, and some
deltoid weakness. Posterior decompression
JOPA 9
would not have addressed the disc degeneration.
Anterior discectomy was indicated. If the fusion
were performed on this 29-year-old female,
she would be at a significant risk of adjacent
segment degeneration later in life. The most
optimal treatment option for her was CTDR,
which would address the mild deformity by
restoring cervical lordosis and disc height
and allow for complete decompression of the
right C5 nerve root to alleviate the arm pain,
numbness, and weakness. The operation
went well, and the radiculopathy and neck
pain resolved after proper postoperative
rehabilitation. Postoperative images are
shown in Figures 4 and 5 below.
References
1. Kelsey J, Githens PB, Walter SD, et al. An epidemiology study of acute
prolapsed cervical intervertebral discs. JBJS Am. 1984;66(6):907-914.
Figure 4
2. Diwan S, Manchikanti L, Benyamin RM, et al. Effectiveness of cervical
epidural injections in the management of chronic neck and upper extremity
pain. Pain Physician. 2012;15(4): E405-34.
3. Hurwitz EL, Aker PD, Adams AH, et al. Manipulation and mobilization
of the cervical spine. A systematic review of the literature. Spine.
1996;21(15):1746-59.
4. Murphy DR, Hurwitz EL, Gregory AA. Manipulation in the presence of
cervical spinal cord compression: a case series. J Manipulative Physiol Ther.
2006;29(3):236-44.
5. Bohlman HH, Emery SE, Goodfellow DB, Jones PK. Robinson anterior
cervical discectomy and arthrodesis for cervical radiculopathy.Long-term
follow-up of one hundred and twenty-two patients. J Bone Joint Surg Am.
1993;75(9):1298–1307.
6.Brodke DS, Zdeblick TA. Modified Smith-Robinson procedure for anterior
cervical discectomy and fusion. Spine. 1992;17(10 suppl):S427–30.
7. Daniel K Park, Eric L Lin. Index and Adjacent Level Kinematics After
Cervical Disc Replacement and Anterior Fusion: In Vivo Quantitative
Radiographic Analysis. Spine (Phila Pa 1976). 2011;20;36(9):721-730.
8. Morio Matsumoto, Eijiro Okada, et al. Anterior cervical decompression
and fusion accelerates adjacent segment degeneration: comparison with
asymptomatic volunteers in a ten-year magnetic resonance imaging follow-up
study. Spine (Phila Pa 1976.) 2010;35(1):36-43.
9.Hilibrand AS, Carlson GD, Palumbo MA, Jones PK, Bohlman HH.
Radiculopathy and myelopathy at segments adjacent to the site of a previous
anterior cervical arthrodesis. JBJS. 1999;81(4):519-528.
10. Moatz B, Tortollani J. Cervical disc arthroplasty: Pros and cons. Surg Neurol
Int. 2012;3(Suppl 3): S216–S224.
11. Zigler JE, Delamarter R, Murrey D, et al. ProDisc-C and ACDF as Surgical
Treatment for Single Level Cervical Symptomatic Degenerative Disc Disease:
Five-Year Results of an FDA Study. Spine. 2012; Dec 5 [Epub ahead of print].
Figure 5
Figure 4. Flexion and Extension postoperative lateral radiographs showing restoration of disc height and
alignment and proper motion at C4-5 with a Total Disc Replacement prosthesis.
10
JOPA
Meniscal Tears: Repair or Resect?
Jeffrey Sommers, PA-C, Miranda Collins MEd, MPAS, PA-C
Marietta College Physician Assistant Program
The normal knee is equipped with a lateral and a medial fibrocartilaginous disc within the joint space,
known as the menisci. The menisci may be overlooked by many when discussing the major functioning
components of the knee; however, meniscal tears are among the most common knee injuries, accounting for
850,000 orthopaedic surgeries per year in the United States.1 Even more concerning is the drastic increase
in meniscal tears in the adolescent population within the past decade. An increase in sports participation in
combination with increasing pediatric musculoskeletal knowledge and diagnostic capabilities have attributed
to a 400% increase of diagnosed meniscus tears in adolescent patients at Children’s Hospital of Philadelphia
from 1999 to 2012.2 The menisci serve multiple functions, with shock absorption and load distribution being
most important. By decreasing direct contact pressure and stress load at the tibio-femoral joint, they act to
preserve articular cartilage and more importantly bone integrity.3 The menisci are positioned in such a way
that they reduce the contact area between the femoral condyles and the tibial plateau by 60%, which in turn
absorbs 50% of the axial load that would otherwise be placed on the articulating surfaces of the underlying
bone.4
Meniscus tears are common injuries encountered by orthopaedic surgeons and often require surgical
intervention. Original treatment for a meniscal tear, regardless of size or location, was a total meniscectomy
until 1948 when Fairbanks introduced a study revealing the negative long term degenerative effects associated
with complete resection of the meniscus, thus leading to a demand for more conservative surgical alternatives.5
With the incidence of meniscal tears in adolescents on the rise and the development of arthroscopy, partial
meniscal debridement along with various meniscal repair methods have been adopted as preferred surgical
treatment options in order to preserve as much normal meniscal tissue as possible. However, controversy
still exists today regarding which option, partial meniscectomy versus tissue sparing meniscal repair, is the
best treatment for meniscal injuries. This paper will review the challenges, benefits, and long-term outcomes
for both partial meniscectomy and meniscal repair.
Anatomy
The main obstacle that orthopedic surgeons encounter
when deciding upon a surgical approach is the location and
type of the meniscal tear. The meniscus is divided into two
regions based on local blood supply. The peripheral one
third of the meniscus is referred to as the red zone and the
central portion is referred to as the white zone. The two zones
merge at the red-white junction. The red zone is supplied by
branches of the popliteal artery, collectively known as the
geniculate arteries. Therefore, this region is composed of
highly vascularized tissue. Central to the red-white junction
is the white zone. This region received its name due to its
lack of arterial blood supply.4 The white zone was thought
to be completely avascular receiving absolutely no contact
with oxygenated blood. However, studies have proven that
this theory is not entirely true. Although the white zone has
no arterial supply, it is believed that it does absorb a rather
limited amount of blood from the circulating synovial fluid.5
Because proper vascularization promotes tissue healing,
simple meniscal tears located within the red zone have been
deemed prime candidates for repair.4 Such lesions carry
a surgical success rate of 90% percent. Whereas, lesions
located greater than 4 mm from the vascularized peripheral
ridge have a success rate of only 50% percent.6
JOPA 11
Historically, when a lesion is located within the avascular central two thirds of the meniscus, or greater
than 3 mm from the peripheral rim, surgical repair is contraindicated and arthroscopic partial debridement
becomes the treatment of choice.7
In addition to the vascular characteristics of a meniscal lesion, clinicians must also formulate the
appropriate surgical approach based on the tear pattern. Meniscal tears are classified as vertical, horizontal,
oblique, or complex; some being more amendable to repair than others. Vertical tears are defined as meniscal
lesions that run in a perpendicular plane to the tibial plateau. Vertical tears can be further subdivided into
vertical longitudinal, vertical radial, and bucket handle tears. A vertical longitudinal tear, which is the most
commonly encountered tear pattern in adolescents, is a vertical tear that runs circumferentially with the
long axis of meniscal fiber arrangement. Vertical radial tears originate from the central avascular zone and
travel toward the periphery in a perpendicular plane relative to the tibial plateau. A bucket handle tear is
defined as a complete vertical longitudinal tear with displacement into the tibiofemoral joint, often causing
complete mechanical obstruction and requiring urgent surgical intervention. Vertical longitudinal tears,
especially those complete in nature and located in the vascular periphery carry the greatest repair potential.
However, as long as complexity and white-white zone involvement is minimal, all vertical meniscal tears
have some degree of repair potential. Horizontal tears are seen more commonly in later adulthood and are
classified as lesions running along the transverse plane, parallel to the tibial plateau. Oblique tears are simply
meniscal flaps that are not confined to a particular plane (vertical or horizontal). Lastly, complex tears are
intricate lesions containing at least two different tear patterns. Complex tears are often the result of long term
degenerative changes and are the least amendable to repair of all tear patterns.8
Partial Meniscectomy
Partial meniscectomies have shown excellent results on a short term basis. However, it is the long
term effects that are of great concern. As previously discussed, the main function of the meniscus is load
distribution. If partial meniscectomy is performed, the normal biomechanical nature of the knee joint
becomes compromised. By decreasing contact area between the meniscus and the femoral condyle or
tibial plateau pressure placed on the bony surfaces of the joint itself increases, ultimately leading to joint
space degradation.9 An inverse relationship exists between amount of viable meniscal tissue remaining post
resection and potential to develop osteoarthritis. Noyes reported that a meniscal debridement of as little as
15-34% increases the direct contact area between the femur and tibia so much as to cause a 350% increase in
axial load on the articular cartilage.4 Using a three dimensional model of the knee and finite element analysis,
E. Pena set out to discover contact area and stress load alterations following various zones of meniscal
resection. The study showed that after longitudinal partial resection there was as much as 100% increase of
compression load on the knee joint.
Interestingly, data revealed that the location of the meniscal debridement was just as influential as
the amount of tissue resected. The meniscus is positioned in such a way that designated portions serve as
maximum load absorbing areas; one such area is the posterior horn of the medial meniscus. Although the full
biomechanical nature of the knee joint becomes compromised with resection of any portion of the meniscus,
the load redistribution following a resection of the anterior horn of the medial meniscus would be minimal
and easily compensated for by the remainder of the intact meniscal tissue, especially the posterior horn.
A resection of the posterior horn of the medial meniscus, however, would cause greater deleterious effects
because it is a maximum load bearing area. Resection of a high stress zone such as the posterior horn would
cause a large dispersion of axial load that cannot otherwise be compensated for, leading to a much greater
compression load directly onto the underlying articular surfaces.10 Therefore, resection of even a minimal
portion of the meniscus can result in a major increased contact area of the deep articular cartilage, which is
the final defense for the underlying bony surfaces of the joint.
Meniscal Sparing Techniques
Based on the biomechanical understanding of the knee joint and the crucial role the menisci play
in preserving bony architecture, it seems logical that meniscal repair better maintains full physiological
function within the joint space and prevents the alterations in axial load distribution seen with partial
meniscectomies. Multiple radiographic studies have been conducted to observe the long term osteoarthritic
effects associated with partial meniscectomy in comparison to meniscal repair. Using cartilage sensitive MRI,
R.J. Williams proved that radiographic changes following partial meniscectomy can be detected as early
12
JOPA
as 5 years post-operatively. The study showed
that 64% of partial medial meniscectomies and
33% of partial lateral meniscectomies revealed
articular cartilage abnormalities on MRI.11 Stein
et al conducted a study comparing meniscal
repair and partial meniscectomy outcomes using
radiographic analysis at an average of 3.4 years
and again at 8.8 years. Although no significant
difference was noted between the two surgical
techniques at 3.4 years, long term follow up at
8.8 years revealed a great deal of radiographic
disparity. The later analysis showed 80.79% of the
repair subjects had joint space preservation and
no signs of osteoarthritic changes as compared
to only 40% of partial meniscectomy subjects.12
Further support of this finding was shown in a
systematic review conducted by Paxton revealing
no radiographic degenerative changes in 78% of
the sample population 10 years following meniscal
repair.13 Brucker proved longevity benefits of
meniscal repair, studying full weight bearing
radiographic analysis 20 years post-operatively
by comparing surgically repaired knees with their
intact contralateral knee and found no significant
osteoarthritic differences.14
Surgical Advancements for White-white Meniscal
Tears
With the amount of evidence in the literature
regarding
the
notion
of increased knee
osteoarthritic progression associated with
fibrocartilaginous tissue loss and increasing
meniscus injuries occurring at younger ages, an
increasing number of surgeons with extensive
fellowship and training in meniscal sparing
techniques have been attempting meniscus repairs
within the red zone as well as of those extending
beyond the red-white junction and into the
white zone. Noyes and Barber-Westin conducted
a prospective study examining whether tears
extending into the avascular white zone can in
fact be repaired. Their results showed that 75% of
complex tears located within the “irreparable” white
zone showed no signs of repair failure on follow
up arthroscopic evaluation as well as no joint line
pain at a mean follow up period of 51 months.15 P.D.
Gallacher found 68% of 87 meniscal tears located
in the central avascular zone required no further
surgical procedure and were ultimately ruled a
successful repair at 49 month follow up.9 Although
meniscal repair within the poorly vascularized
central portion of the meniscus has been proven
feasible, success rates are still less favorable than
ultimately desired. Therefore, additional surgical
advances have been recently introduced, all of
FIGURE 2. Vertical Meniscus Tear
FIGURE 4. Probe pulling in the Vertical Tear
FIGURE 1. Meniscal Repair of the Vertical Tear
JOPA 13
which share the common goal of meniscal preservation to assure maximum shock absorption within the
knee joint. Such advances include abrasion therapy and fibrin clot injection.16 Abrasion therapy, or rasping,
is performed by creating a small radial incision within the healthy peripheral meniscus surrounding the
centralized tear. The rasping technique creates a means of vascular communication from the healthy red-red
zone to the lesion located within the poorly vascularized white-white zone. In doing so, the vascular area
within the meniscus is expanded, allowing for increased amounts of growth factors and blood products to
reach the injured tissue.16 Injection of fibrin clots into the repaired lesion also functions by increasing the
vascular environment surrounding the repair. It has been recorded that infusion of a fibrin clot during repair
reduces failure rates from 41% to 8%.6
Surgical techniques including allograft meniscal transplantation and collagen meniscal implantation
have developed to provide symptomatic relief, functional improvement, and joint preservation for postmeniscectomy (both partial and total) patients. Allograft meniscal transplantation is a technique indicated
for patients, particularly under the age of 50 with the absence of severe osteoarthritic condition, that are
experiencing symptoms associated with early degenerative changes following previous meniscus resection.
This technique utilizes precisely measured and preserved cadaveric meniscal tissue implanted and fixed
directly into the meniscal deficient joint space using open or arthroscopic technique.17 Verdonk et al not only
examined the degree of functional improvement of the augmented knee, but also the longevity of the allograft
meniscal implant. Using the modified Hospital for Special Surgery (HSS) scoring system which examines
various functional parameters including range of motion, flexion, instability, and even pain, examiners
revealed a significant increase of mean functionality score from 60.1 (out of 100) pre-operatively to 88.6 at
final post-operative follow up (mean 7.75 years). Of the 100 test subjects enrolled in the study, only 21 allograft
meniscus implants at mean follow up of 7.75 years were unstable and deemed a failure based on the rigid
criteria of knee functionality measures and second look arthroscopy outlined in the Kaplan Meier Analysis
model.18 LaPrade et al examined functionality of the affected knee at a minimum of 2.5 years following allograft
meniscus transplantation. According to pre-operative and post-operative results of the Modified Cincinnati
Subjective Survey, 91% of transplant subjects professed greater functionality with decreased pain symptoms
as well as a significant increase in objective improvement based on the IKDC objective test results.19
In the absence of cadaveric meniscal tissue, collagen meniscal implantation technique is evolving
as a possible alternative. Collagen meniscal implantation consists of a type I collagen fiber graft derived
from bovine Achilles tendons that is surgically placed within a resected meniscal zone. Collagen meniscal
implantation has shown significant advancements in joint space preservation when compared to knees that
have undergone partial meniscectomy. This treatment was studied by Zaffagnini et al who detected significant
joint space narrowing of the affected knee in the partial meniscectomy group, as compared to the collagen
meniscal implanted knee that revealed no significant narrowing at 10 years post-operative.20
Conclusion
Meniscal injuries are a common occurrence in the United States with an increased incidence in
the adolescence population. As a result, it is imperative that orthopaedic clinicians be familiar with the
most beneficial (short term and long term) surgical techniques available to patients. Although meniscal
debridement (partial meniscectomy) has been a viable treatment option for injuries, long term studies
showing the development of degenerative disease prove otherwise, which is a significant consideration when
determining surgical options for younger patients. Instead, clinicians should consider a meniscal sparing
technique regardless of the location or complexity of the lesion. Advanced repair techniques for lesions
within the avascular zone, such a rasping and fibrin clot injection, have promising results that promote
healing and decrease failure rates. For complex tears in which repair is not an option, meniscal implantation
devices provide a sufficient alternative.
References
1. Green III J.R. Arthroscopic Meniscus Repair: A minimally invasive
method to repair torn knee cartilage. UW Medicine: Orthopaedics and
Sports Medicine. 2013.
2.Contemporary Pediatric Staff. Pediatric knee injuries: What to do
about a 400% increase in 12 years. Contemporary Pediatric: expert
clinical advice for todays pediatricians. 2011.
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http://contemporarypediatrics.modernmedicine.com/contemporarypediatrics/news/modernmedicine/modern-medicine-news/pediatricknee-injuries-what-do-abo
3.Bae J.Y., Park K.S, Seon J.K, Kwak D.S., Jeon I., Song E.K. Biomechanical
analysis of the effects of medial meniscectomy on degenerative
osteoarthritis. Med boil engcomput. 2012; 50: 33-60.
4.Noyes F.R. , Barber-Westin S.D. Management of meniscus tears that
extend into the avascular region. Clinics in sports Medicine. 2012; 31:
65-90.
5.Fox A.J.S, Bedi A., Rodeo S.A. The basic science of human knee
menisci structure, composition, and function. Sports Health: a
multidisciplinary approach. 2012; 4: 340- 351.
http://sph.sagepub.com/content/4/4/340
6.Shybut T., Strauss E.J.. Surgical Management of Meniscal Tears.
Bulletin of the NYU Hospital for Joint Disease. 2011: 69 (1): 56-52.
7.Krych A.J. et al. Arthroscopic repair of isolated meniscal tears
in patients 18 years and younger. The American journal of sports
medicine. 2008; 36 (7) 1283-1289.
8.Maffulli N., Giuseppe Longo U., Campi S., Denaro V. Meniscal Tears.
Dove Press Journal: open access journal of sports medicine. 2010; 4554.
9.Gallacher, P. D. White on white meniscal tears to fix or not to fix?.
The Knee . 2010; 17: 270-273.
10.Pena E. et al. Finite element analysis of the effect of meniscal tears.
Clinical Biomechanics 20. 2005; 20: 498-507. Retrieved from http://
journals.ohiolink.edu/ejc/pdf.cgi/Pea_E.pdf?issn=02680033&issue=v2
0i0005&article=498_feaoteamohkb
11.Williams III R.J. et al. Mri evaluation of isolated arthroscopic
partial meniscectomy patients at a minimum five-year follow-up. HSS
journal : the musculoskeletal journal of Hospital for Special Surgery
. 2006; 3(1): 35-41. Retrieved from http://europepmc.org/articles/
PMC2504089/pdf/11420_2006_Article_9031.pdf
12.Stein et al. Long term outcomes after arthroscopic meniscal repair
versus arthroscopic partial meniscectomy for traumatic meniscal
tears. The American journal of sports medicine. 2010; 38 (8): 15421548.
13.Paxton E Scott, Stock M.V., Brophy R.H. Meniscal repair versus
partial meniscectomy: a systematic review comparing reoperation
rates and clinical outcomes. Arthroscopy: the journal of arthroscopic
and related surgery.2011; 27 (9): 1275-1288.
14.Brucker P. U., Arndt von Campe,P.U., Meyer D. C., Arbab D., Stanek
L., & Koch P. P. Clinical and radiological results 21 years following
successful, isolated, open meniscal. The Knee. 2011; 18: 396-401.
Retrieved from http://journals.ohiolink.edu/ejc/pdf.cgi/Brucker_P.U.p
df?issn=09680160&issue=v18i0006&article=396_carr2fmriskj
15.Noyes FR, Barber-Westin SD. Arthroscopic repair of meniscal tears
extending into the avascular zone in patients younger than twenty
years of age. Am J Sports Med 2002; 30:589-600. http://journals.
ohiolink.edu/ejc/pdf.cgi/Noyes_Frank_R.pdf?issn=03635465&issue=v3
0i0004&article=589_aromteyttyoa
16.Longo et.al. Biological strategies to enhance healing of the
avascular area of the meniscus. Stem Cells International. 2012;1-7.
17.Zaffagnini S, Muccioli GM; Marcheggiani, Muccioli GM; Lopomo N,
Muccioli GM. Prospective long-term outcomes of the medial collagen
meniscus implant versus partial medial meniscectomy: a minimum
10-year follow-up study. Am J Sports Med. 2011; 39: 977–985. http://
journals.ohiolink.edu/ejc/pdf.cgi/Zaffagnini_Stefano.pdf?issn=036354
65&issue=v39i0005&article=977_plootmmam1fs
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JOPA 15
Common Meniscal Tears
Surgical perspective by Daniel P. Bouvier, MD
FIGURE 1
FIGURE 2
Figure 1 is a illustration of a complex or degenerative tear. Figure 2 is a saggital MRI image showing a tear of
the posterior horn of the medial meniscus. The complex tear involves meniscal disruption in both vertical
and horizontal planes.
FIGURE 3
FIGURE 4
Figure 3 is an intraoperative arthroscopic image of a degenerative medial meniscal tear. Figure
4 shows the meniscus after meniscectomy. Surgical perspective: preoperative considerations in
degenerative tears such as this involve careful assessment of symptoms (arthritic vs. mechanical), onset
of symptoms (acute in a previously asymptomatic knee vs. progressive), and localization of symptoms
(joint line vs. global). Negative prognosticators for success may include articular cartilage loss in the same
compartment, and meniscal extrusion. Preoperative corticosteroid injection may play a role in evaluating/
delineating symptoms (arthritic vs. meniscal) by duration and/or completeness of relief with the injection.
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JOPA
FIGURE 5
FIGURE 6
Figure 5 is an illustration of a horizontal meniscal tear. Figure 6 is a saggital MRI image showing a horizontal
cleavage tear of the lateral meniscus.
FIGURE 7
FIGURE 8
Figure 7 is an intraoperative arthroscopic image of a complex medial meniscus tear with a displaced flap as
well as a horizontal cleavage component. Figure 8 shows the meniscal resection back to a stable rim.
Surgical perspective: in this case, surgical considerations follow the principles of meniscal resection, which
is to remove enough meniscus to leave a stable rim that is not susceptible to retear. That means here,
choosing the smaller of the two leaflets (usually the inferior one) and not leaving any abrupt transition
zones that may be a leading edge to retear. Then one should balance the anterior portion of the resection
by switching portals and tapering the anterior portion of the resection.
JOPA 17
FIGURE 9
FIGURE 10
Figure 9 is an illustration of a transverse or radial meniscal tear. Figure 10 is a coronal MRI image showing a
free edge tear of the medial meniscus with marked truncation of the free edge.
FIGURE 11
FIGURE 12
Figure 11 intraoperative arthroscopic image of a radial tear. Figure 12 shows resection of the tear.
Surgical perspective: radial tears are troublesome because they often in younger patients, are not
amenable to repair, and if traverse the entire meniscus, destroy the meniscal biomechanics. In those cases,
the ability of the meniscus to resist hoop stresses is gone and large meniscal resections are necessary.
Even when the radial tear is halfway through the meniscus, resection must taper to the apex of the tear
from anterior and posterior to it, which requires more tissue removal.
18
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FIGURE 13
FIGURE 14
Figure 13 is an illustration of a detached buckle-handle meniscal tear. Figure 14 is a saggital MRI image of a
medial meniscus bucket-handle tear with a flipped fragment in the intercondylar notch resulting in a double
PCL sign.
FIGURE 15
FIGURE 16
Figure 15 is an intraoperative arthroscopic photo of a displaced buckle handle tear. Figure 16 is an
intraoperative photo showing the meniscus reduced and repaired. Surgical perspective: these are often seen
in traumatic knee injuries and in conjunction with ligament injury. Considerations here are to determine
which zone of the meniscus is torn and whether it’s a true vertical tear in the red zone. This may make it
repairable, especially in a younger patient who is also having a concomitant ACL reconstruction. This setting
offers higher healing rates with repair of the meniscus. Meniscal preservation in this population is preferable
and one might consider repair in that setting whereas they may not in an isolated bucket-handle tear in a
middle aged patient with some chondral surface wear.
JOPA 19
FIGURE 17
FIGURE 18
Figure 17 illustrates a vertical or longitudinal meniscal tear. Figure 18 is a saggital MRI image showing a
vertical tear of the posterior lateral meniscus in the red/white junction.
FIGURE 19
FIGURE 20
Figure 19 is an athroscopic photo of a vertical tear. Figure 20 shows the stable repair of the vertical tear.
Surgical perspective: considerations here involve the location of the vertical tear, it’s length, and the
condition of the meniscal body. Tears in the periphery, greater than a centimeter in length (unstable), and
in which the body of the meniscus is not extensively damaged (can be coapted well) should be considered
for repair.
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JOPA
NCCPA Orthopedic CAQ Sample Exam Question
A 20-year-old man who plays baseball on his college team comes to the clinic because he
has had pain in the right elbow for the past three weeks. The pain began approximately
one week after the beginning of the baseball season. Physical examination of the elbow
shows full range of motion in flexion, extension, supination, and pronation. No pain is
elicited on varus or valgus stress of the elbow. Dorsiflexion of the right hand against
resistance immediately elicits pain that is localized to the lateral aspect of the elbow.
Which of the following is the most likely diagnosis?
(A) Biceps tendinitis
(B) Fracture of the radial head
(C) Lateral epicondylitis
(D) Olecranon bursitis
(E) Sprain of the lateral collateral ligament
Content Area: Sprains and Soft-Tissue Pathology (23%)
Critique
This question tests the examinee’s ability to recognize signs and symptoms of a
musculoskeletal disorder to determine the most likely diagnosis. The correct answer is
Option (C), lateral epicondylitis. Overuse or repetitive motion activities involving wrist
extension and/or supination are common causes of lateral epicondylitis. Clinical
manifestations usually include pain in the lateral aspect of the elbow and the dorsal aspect
of the forearm that is exacerbated by use. Physical examination usually shows maximal
point tenderness over the lateral epicondyle and/or the area overlying the extensor carpi
radialis brevis muscle. Extension or supination of the wrist against resistance typically
elicits pain.
Option (A), biceps tendinitis, is incorrect because this condition involves inflammation of
the long head of the biceps tendon, which causes pain in the anterior aspect of the
shoulder.
Option (B), fracture of the radial head, is incorrect because the patient has no
history of substantive trauma. In addition, the physical examination findings of full range
of motion in all planes and provocation of pain on dorsiflexion of the wrist against
resistance point away from this diagnosis as a possibility.
Option (D), olecranon bursitis,
is incorrect because this condition involves inflammation of the bursa overlying the
olecranon process and none of the physical examination findings in the patient described
are suggestive of this condition.
Option (E), sprain of the lateral collateral ligament, is
incorrect because the physical examination finding of no pain elicited on varus or valgus
stress of the elbow excludes this condition as the most likely diagnosis. Additionally,
activities that involve overhead throwing, such as baseball in the patient described, are
more likely to involve the medial collateral ligament rather than the lateral collateral
ligament.
JOPA 21
Of Powder Plaster, Overhead Traction
and Broomstick Prosthesis
Reza Ghadimi, PA
Albuquerque, NM
When I entered into the world of medicine
back in the middle of the last century the world
was just entering a new era in healthcare. It
was an old world with new ideas. We were just
recovering from World War II and like all wars,
although the fighting was over, the casualties
lived on. No profession continues to deal with
victims of war more than medicine.
I was a fourteen year old teenager with a
big head when a doctor friend of my father offered
me a summer job at his hospital in Tehran. Soon
after the start of that job I became interested in
orthopaedics and have worked in that field ever
since. My grandmother was a medicine woman
who had an immense knowledge of folk remedies
with a great following. I grew up in her care and
watched and learned much of her hands-on way
of patient care. As an acolyte of my grandmother,
I had many experiences assisting her in dealing
with injuries. Orthopaedics requires a real handson care of the patient, so it was just natural for me
to gravitate toward the field.
Much has changed in the world of
healthcare in the last fifty years and orthopaedics
has contributed plenty to that change. These are
the stories of my observations and experiences
that have taken me through all these years of
practicing medicine in seven countries on three
continents.
The year was 1958 in Tehran when
I started my first job in medicine washing
instruments, sterilizing and packaging them.
The hospital was a small private twenty bed
institution for chronic diseases with only one
surgical suite. It was not long after when I was
introduced to the field of orthopaedics and
became fascinated by it. It started one day as I
was passing the ER and heard the cry of a young
boy. I stuck my head in to investigate and saw
my doctor friend attending to the boy’s arm. He
saw me and beckoned me to enter. He explained
that the boy had broken his arm and he was going
to cast it. He then showed me how to wrap the
arm with muslin, which is a cotton fabric that was
used extensively as wound dressings or undercast padding in those days. He opened a bucket
22
JOPA
FIGURE 1. Reza Ghadimi in front of
Tehran Hospital - Circa 1959
full of white powder and explained that it was
special fast setting plaster. He took a handful
and mixed it with water, turning it into a paste
and then applied it unto the muslin wrap on the
boy’s arm and let it dry. It soon became hard. I
was fascinated by the process and from then
on volunteered to apply the cast to those who
needed it.
Earlier that summer my father had a
room added to our house and I had watched the
construction worker plaster the room. They
applied the plaster with a trawl, working it back
and forth, while explaining that the process
created heat that cured and harden it into a
smooth luster. I applied the same technique
and quickly learned that the heat produced by
the plaster can burn the patient, but the use of
cold water keeps the process in check. I began to
master the art of applying casts to injured parts of
the body and my casts were not only technically
done well, they also looked good.
The hospital was staffed mainly by
internists. We had an emergency department,
which really wasn’t suited for acute care. There
were no orthopaedic doctors on our staff, but
they did come to the hospital to visit patients
who needed ortho consults. On one such
move into the surgical side of orthopaedic
medicine so that by the time I moved to
New York City in 1962, I had a good bit of
experience for a seventeen year old from
the foothills of the Alborz Mountains, Iran.
The first few years were very
tough in America. My lack of knowledge
of english made it difficult to get a job
anywhere. But once I found my way
around, I was able to land a job working
nights as an orderly in the ER at a city
hospital. The opportunity was all I needed
to propel myself back into the world
of medicine. The hospital supported a
large residency program and the young
orthopaedic residents who covered
the ER at night soon came to depend
on me to teach them casting. There I
discovered plaster bandages. It was nice
FIGURE 1. Reza Ghadimi (on the left) in the surgery
to avoid mixing plaster from a bucket and
suite of Princess Margaret Hospital on the Island of
spreading it over muslin.
Dominica after hurricane David, several decades ago.
Soon after the Vietnam War
started, which put America in a tailspin. Along
occasion, the visiting orthopaedic doctor needed
with millions of others, I was drafted. To avoid
a cast applied to a man’s arm and I was asked to
the Army, I joined the Air Force and got myself
apply it. He became enthralled by my talent and
into the medical corps and succeeded in getting
made several comments on how beautiful my cast
a position at Wilford Hall USAF Hospital in San
looked. This further enticed me to make my cast
Antonio, Texas.
work as appealing as possible and I used every
Military orthopaedics was a new challenge
opportunity to improve my techniques at work.
and an exciting place to be. Vietnam supplied
In those days there were no such things as
us with a multitude of war injuries. My surgical
plaster bandages. Plaster came in a bucket.
knowledge got me into the operating suites and
You wrapped the part of the body needing
my good looking casts were demanded by many
immobilization with muslin, applied wet plaster
patients. I learned new applications for plaster;
over it, and smoothed it as you went. It was a
body casts for spine injuries, PTB casts, Minerva
messy, difficult and often inaccurate work. The
jackets, shoulder spica’s, single and double hip
patient was often in pain and would not keep still
spica casts were among a few new ones I learned
for the plaster to set, causing cracks and breaks
to apply. Many of our patients were victims of
in the plaster. These required repair with more
land mines and other explosive type devices and
plaster, which often resulted in a very heavy cast.
had lost all or part of their limbs.
Removing a bulky cast was also difficult. With
Wilford Hall had a brace shop and building
experience, I became good in allowing the plaster
prosthesis was another art I was introduced to.
to half dry before applying it and by rubbing it
Original prostheses were literally made of sticks
as I smoothed it, helped it to cure and set faster.
and leather. They were heavy, uncomfortable and
This reduced the application time and kept the
difficult to apply, and patients hated them. I had a
cast lighter thus lessening the discomfort of the
veracious appetite for learning and trained many
patient. This talent got me the reputation as the
different providers including doctors, physical
“cast man.” Years later, while serving in the US
therapists, prosthetists, and other ortho techs.
Air Force, I received a commendation medal for
I learned numerous ways of putting an injured
my work as a “cast technician”. To my knowledge,
person in traction including bucks traction,
the only one ever given!
overhead traction, skin traction, skeletal traction
My work sterilizing instruments
and many more ways of stringing a human being
familiarized me with needles, hemostats,
in a contraption.
syringes, curettes, ring forceps, and many other
Thousands of surgical cases later and
instruments. This knowledge further helped me
JOPA 23
many thousands of casts behind me I look back on all the changes and wonder if they have improved
patient care. We have come a long way from the days of ether for anesthesia, re-usable syringes and
needles, rusted instruments and powder plaster. Today synthetic casting tapes have replaced old
heavy plaster. IM rods, hip and knee prosthesis, and arthroscopic surgery have done away with long
immobilization. Diagnostic tools such as MRI and CT scan identify problems more accurately. Traction
is all but forgotten and advances in prosthetics design and state of the art materials get patients back on
their feet much faster. Amputees and handicapped people participate in sports and even partake in the
Olympics. I have seen many changes, yet we are still struggling to bring needed healthcare to many people
of our country and the world.
Today medicine has become more technical than an art. Patients fill their history and make their
appointments online. Smart phones and computers take their vital signs and relay it to their electronic
records. Medical software identify possible medication conflict and suggest differential diagnosis. Internet,
robotics, nano-technology and wireless communication are helping us be in many places at once and
treat patients near and far. Providers spend little to no time with patients and depend on this technical
information to diagnose and treat patients. Good or bad, here we are. Yet we have a long way to go to
what medicine should be in the twenty first century. Still the experiences of today will be the memories of
tomorrow. What tales of the past will these new doctors tell fifty years from now, I wonder.
Share your Experiences with JOPA
The Journal of Orthopedics for Physician Assistants (JOPA) provides
a unique forum for sharing ideas and experiences with your colleagues. JOPA is
the first journal representing the physician assistant orthopedic specialty and
unique voice for all in the profession. We can all learn and grow from our shared
experiences.
24
JOPA
JOPA 25
Direct Anterior Approach Total Hip Arthroplasty:
A Comparative Review of Surgical Approaches to the Hip
Mark Carbo, M.S., PA-C
Orthopaedic & Sports Medicine Specialists, Alexandria, LA
Osteoarthritis (OA), one of the most common forms of joint disease, creates a high economic
burden secondary to the effects of disability and medical cost. Comorbidity diseases add to this economic
burden and may prolong rehabilitation in some patient populations. Osteoarthritis disables approximately
10% of people who are 60 years and older, compromises the quality of life of more than 20 million
Americans, and costs the United States economy more than $60 billion per year in health care dollars.1
Economic cost secondary to work-related losses adds to the indirect costs of OA with the growing numbers
of younger, working adults suffering with OA.
The current trends in surgical approaches to the hip have centered on less invasive methods
and specifically designed instrumentation that result in an early recovery and return to the workforce. A
current search of PubMed with “minimally invasive surgery” (MIS) retrieves over 12,000 articles, however,
there seems to be a wide variety of definitions of what is meant by “minimally invasive”. Lovell describes
minimally invasive surgery as the least damaging procedure to the surrounding structures and tissue.4 The
direct anterior approach (DAA) to the hip is a MIS technique that takes advantage of a true intermuscular
and internervous plane allowing rapid, direct and wide exposure to the hip joint, while minimizing soft
tissue disruption. This approach is discussed as it benefits the patient’s recovery with a muscle sparring
dissection, which yields faster post-op recovery, with a decreased post-op dislocation risk. 3,4 This article
will compare the DAA hip to the mini posterior approach (MPA), which is also considered as minimally
invasive by many authors. Rapid recovery of hip function and restoration of gait ability following total hip
arthroplasty will save health care dollars by shortening rehabilitation and allow rapid return of working
adults back to the workforce.
HISTORICAL PERSPECTIVE
The approach to the surgical hip has been performed through various procedures including
anteriorly as first described by Carl Hueter, a German physician, in his publication of Der Grundriss der
Chirurgie (The compendium of Surgery) in 1881.5 Throughout the years, the popularity of the anterior
approach moved to the English-speaking world with Marius N. Smith-Petersen. This technique is commonly
referred to as the “Smith-Petersen approach”.5 Many other surgeons have continued to teach this approach
and have contributed to the advancement in instrumentation to improving exposure and reducing tissue
damage. Kristaps Keggi demonstrated the first presentation of the approach to the American Academy
of Orthopaedic Surgeons (AAOS) in the early 1970’s, Keggi continues to teach the DAA to orthopaedic
residents at Yale University today.
This anterior approach remains a standard approach to the hip in pediatric orthopedic surgery for
developmental hip dysplasia. In the adult patient, it is used for exposure of the anterolateral aspect of the
femoral head, neck, and acetabulum. The exposure also lends itself for the treatment of femoroacetabular
impingement and minimally invasive total hip arthroplasty.5 With advancements in instrumentation and
better designs of femoral stems, the anterior approach has regained popularity as a versatile approach to
the hip in the adult patient.
SURGICAL TECHNIQUE
There are many options with tables and attachments to the standard OR bed that are available to
aid in positioning the patient and serve to increase exposure in direct anterior approach to the hip. The
standard OR table has been used in DAA hips with reproducible and successful outcomes for many years.
More recently, Dr. Joel Matta popularized the procedure through the use of OSI PROfx table that places
both ankles in a boot support configuration that can add axial traction and rotation of the hip to aid in the
26
JOPA
procedure. Other variations include the arch
table, which attaches to the standard OR bed for
femoral rotation and distraction.
For the purpose of this article, the
standard OR table will be discussed for
utilization and exposure. The direct anterior
hip approach can be performed on a standard
operating room table in the supine position
to obtain full hip extension and adduction to
approach the acetabulum and femoral canal.
The head attachment of the operating room
table is moved to the end of the bed to allow
the patients perineum to be placed at the table
break. This will allow for extension of the hip
during the femoral preparation (Figure 1). An
arm board is placed on the foot of the table on
the nonoperative leg, allowing added abduction
of the nonoperative limb and added adduction
of the operative limb that is essential for femoral
preparation. The operative hip and lower limb is
prepped and draped in the sterile fashion.3,4
The incision begins 2 cm distal and lateral
to the anterior superior iliac spine (ASIS) and
continues distal along a line parallel the ASIS and
the fibula head at the knee. The total incision
is approximately 8-10 cm (Figure 2). Dissection
is then carried down to the fascia covering the
tensor fasciae latae, and then incised along the
fibers. A finger dissection is continued under
the fascia medially and then down through the
intermuscular plane between the tensor and
the sartorius muscle, separating the two muscle
bellies. A blunt cobra retractor is then placed
in the saddle region along the superior lateral
femoral neck. A cob elevator may be required to
tease the rectus off the superior-anterior edge of
the neck. This allows dissection in the interval
between the tensor and the rectus. A second
blunt cobra retractor is placed at the inferior
medial neck to maintain this interval. At this
point, the circumflex vessels should be in view
at the distal incision, and care must be taken to
cauterize or ligate these vessels. 3,4
The anterior capsule is excised with an “H”
incision to reveal the anterior femoral neck. Two
cobra retractors can be placed directly around
the superior and inferior femoral neck inside the
remaining capsule. The inferior medial capsule
is released from the medial calcar using subtle
figure-of-four position; a mark can be placed at
this time to prepare for the femoral neck cut with
one “finger breadth” above the lesser trochanter.
The neck cut is made in-situ and the femoral head
is removed with a cob elevator or corkscrew.
Figure 1
Figure 2
JOPA 27
The labrum is then excised to aid in visualization of the acetabulum and acetabular retractors are placed.
Reaming of the acetabulum is carried out with a double offset reamer to protect the tissue and allows
anatomic placement of the reamer in the obese patients.4
Once the proper acetabulum sizing has been accomplished with reaming, the femur is positioned
for broaching. A bone hook is placed in the femoral canal and distal / upward retraction is used to
elevate the femur and assess for release of residual capsule that may require releasing which will aid in
elevation for broaching. Next, while maintaining elevation of the femur, a pointed Hohmann retractor is
placed proximally behind the greater trochanter and an acetabular or cobra retractor is placed medially.
Specifically designed retractors and broach handles facilitate adequate exposure and can be seen in figure
3. The foot of the bed is lowered to extend the hip and abduction of the non-operative leg with adduction
and external rotation of the operative leg provides the visibility for broaching of the femur. Placing the
bed in slight Trendelenburg will allow for further lowering of the foot of the bed while maintain sterility.
Broaching is then carried out with a double “off-set” broach handle (Figure 4). Once the final broach has
been seated and trialed, the implants are placed in the same manner and reduction of the hip with range of
motion can be performed to check stability. The non-operative leg can now be placed in neutral position
to allow an accurate assessment of leg lengths. Fluoroscopy can be used to check cup placement and
stem alignment at this point. 3,4 The fascia of the tensor fascia lata muscle is closed with absorbable suture
followed by closure of the subcutaneous layer. The skin is closed in the usual fashion of the surgeons’
preference.
NAVIGATION
The use of a small incision does not necessarily mean it is minimally invasive. The amount
of manipulation and compromise to the surrounding tissue beneath the incision is what classifies as
“minimally invasive”. With more minimally invasive surgeries through various approaches, skeptics worry
about the addition of new risks due to poor visualization and increased difficulty in positioning of the
prosthesis. With malpositioning of the component, increased risk of dislocations and early wear of poly
liners have been documented. To help eliminate malpositioning of the acetabular cup in MIS-THAs, the use
of computer navigation has been useful.6,7
Sugano reviewed the navigational procedures performed by a single surgeon on both the posterior
approach and the direct anterior approach to assess cup placement. They looked for variations in cup
placement in the two groups with 400 degrees of inclination and 150 degrees of anteversion as being the
target placement.6 They noted no significant differences in the recorded cup inclination or anteversion
Figure 3
28
JOPA
Figure 4
between the two groups. They concluded that the anterior approach resulted in a faster recovery time, but
no difference in hip scores were seen after 6 months.6
LEARNING CURVE
Safe, accurate and reproducible results are what every surgeon desires with each procedure they
perform. As with every surgical procedure, there is a learning curve to achieve reproducible results. A
surgeon interested in learning the direct anterior approach for THA should attend a cadaver workshop and
visit with a surgeon already performing the procedure to help minimize this curve.4
Current literature regarding the learning curve of the anterior approach by John Masonis8 looks at
a single surgeons outcomes on the initial 300 consecutive cases. These cases were grouped in chronologic
order (1-100 = group 1; 101-200 = group 2; and 201-300 = group 3). The procedures were performed through
a single incision with the DAA. Fluoroscopy was utilized to assess cup placement and stem alignment in
all 300 cases. A retrospective review looked at operative time, blood loss, complications, dislocations,
infection, and neurologic injury. Radiographic assessment of cup abduction angle was measured and leg
length discrepancy was noted.
Results showed improvement with the increase number of surgeries performed. There was only one
dislocation and this was noted with group 3 which occurred 9 months post-op while the patient was putting
on shoes with the operative leg on the stairs. Three calcar fractures occurred with group 1 and were
treated with cables. There were no neurologic injury demonstrated and one deep infection that was treated
aggressively with irrigation, debridement and intravenous therapy.8
The learning curve continued through the first 100 cases and continued to show significant
improvement with reduction of fluoroscopy, decreased surgery times, and improved leg length equalization.
Masonis found the learning curve for accuracy and patient outcomes to be somewhat flat and attributed
this to the use of intraoperative fluoroscopy and a true intermuscular approach.8
Other complications that have been documented include lateral femoral cutaneous nerve
damage, damage to the circumflex vessels, femoral neurovascular bundle injury, muscle damage, femoral
perforation, stem malpositioning, cup malpositioning, and traction table-related injuries.9, 10, 11 Improper
placement and utilization of retractors have added to some of the complications listed. Utilizing
specialized retractors, dual off-set reamers and broach handles, these complications can be avoided
thereby limiting risk to patients.
Meneghini described muscle damage to the tensor fasciae latae and the gluteus medius and
minimus during a cadaveric study in the lab.11 However, review of the methods and approach in this study
was limited by incomplete acetabular retractor placement, the inability to extend the hip to aid in femoral
preparation, and the resulting disproportionate releasing of the short external rotators.11 The sample size
of this study was greatly limited with only 6 cadavers (12 hips).
COMPARISON OF THE DAA TO THE MPA
A search of current literature reveals numerous studies examining minimally invasive hip surgeries
comparing patient outcomes. Measurements of patient outcome scores are generally assessed at 6 weeks,
3 months, and 2 years. Nakata3 published the first comparative study on DAA and MPA in consecutive
patients by a single surgeon looking at objective functional outcome measures as early as 3 weeks. He
examined 182 consecutive patients (195 hips) from May 2003 to December 2006. Nakata changed his
approach from MPA in March 2005 and initiated the muscle-preserving MIS-THA by DAA. The groups were
equal in all demographic categories (i.e. age, body mass index, pain index, and mobility). The DAA group
consisted of 99 hips and the MPA category contained 96 hips.3
In the posterior approach group, the patients were placed in the lateral position on a standard table,
and had a reverse U-shape incision of the short rotators and capsule in one bulk flap. After preparation of
the acetabulum and femur, the gluteus minimus and the muscle-capsular flap were reattached. This was
implemented utilizing a modified Kessler method with a pullout suture technique through the trochanter to
prevent post-op dislocations.3
Patients in the anterior approach group were placed on a standard orthopedic table in the supine
position. The approach was through the intermuscular and internervous planes of the tensor fascia lata
and sartorius muscle belly superficially and the tensor and rectus deep. The use of fluoroscopy or intraoperative x-ray was not utilized during or after cup impaction for inclination and anteversion. Following
JOPA 29
placement of the prosthesis, the fascia was closed.
Epidural analgesia was administered for 36 hours after surgery and patients were placed on oral
non-steroidal anti-inflammatory for 7 days. Patients began physical therapy on the first postoperative day
with full weight-bearing. Discharge from the hospital was allowed once a patient was able to perform a
single-leg stance for more than 5 seconds. The rehabilitation protocol was identical for both the MPA and
the DAA group.3
All aspects of the procedure were evaluated from incision to closure of the wound for operative
time, blood loss, and drain outputs postoperatively. Radiographic imaging of the pelvis and femur were
obtained with assessment of the cup inclination and anteversion angle, and positioning of the cup within
the safe zone of Lewinnek method.3, 13 The stem was evaluated on lateral x-rays with 30 degrees anterior to
posterior being considered netural.3
Time to ambulation with the assistance of a single-point cane greater than 200 meters, time
necessary to complete a 50 meter walk, time required to perform a single-leg stance greater than 5 seconds,
and the presence of a Trendelenburg sign were the measurement endpoints of the study. Hip function was
also assessed clinically with scores for categories of pain, mobility, and gait.3 These measurements were
recorded preoperatively, and at 5 days, and 3 weeks after surgery. The direct anterior group required
less time for these categories than the posterior group in all areas. At 3 weeks post-op, 34% (34) of the
DAA group required no assistive walking aid as compared to 19% (18) of the MPA.3 In addition, significant
difference was found in the 50-meter walk times between the two groups.
Ninety-nine percent (98) of the cups in the DAA group had been implanted within the safe zone of
Lewinnek method, but only 91% of the cups in the MPA group were positioned in the safe zone.13 Proper
alignment within the safe zone reduces early eccentric wear within the poly, early poly fracture, and the
risk of dislocation.
Nakata concluded that the muscle-preserving MIS-DAA THA is a more useful and effective procedure
for rapid functional recovery than THA performed by MPA.3 Both approaches were performed through
mini incisions; however, the management of the soft tissues (muscles and tendons) more accurately defines
a procedure as minimally invasive because it is the function of these structures that affects the early
recovery.
OTHER USES FOR THE ANTERIOR APPROACH
The Smith-Petersen approach to the hip has been utilized for various procedures to gain access to
the anterior hip. The approach has been modified to fit the procedure being performed and has continued
to gain popularity in primary THA. A revision THA is very challenging through any approach, but the
anterior approach incision can be modified to accommodate a revision also. The mini incision can be
extended proximal and distal to allow for exposure in more complicated revisions.10
Bilateral THA can be performed through the anterior approach using a standard operating table
by a single surgeon without re-draping the patient. Patients requiring bilateral hip replacements benefit
with only one hospitalization, rehabilitation, and one time under anesthesia. The time for rehabilitation
of bilateral hips is approximately the same for a single hip in a patient that has advanced degenerative
changes of the non surgical hip.
Simultaneous bilateral hips were reported by Mast et al12 using the special tables and two surgeons
performing the procedures. Mast et al reported on safety and early recovery with this study. In this series,
no complications could be directly attributed to this technique.12 However, with a 50% reduction for
bilateral procedures, the economic disadvantage to the surgeon for reimbursement of the second hip may
be a deterring factor.
CONCLUSION
In conclusion, current literature outlines several important factors that affect patient outcomes
with minimally invasive approaches to the hip. These factors influence the stability and functionality of
the hip following surgery. There is a learning curve with the DAA that improved significantly within the
3 hip groups as seen with Masosnis8 in regards to operative time in surgery, blood loss during surgery,
cup placement within the target area, and complications. The use of specialized retractors, reamers, and
broaches have aided in visualization and tissue protection to reduce complications and help with the
learning curve4.
30
JOPA
Hip precautions are a part of patient education that starts with the first postoperative day following
THA for every patient. With DAA THA, the traditional hip precautions are not required. The patient is able
to resume full motion of the operative hip under the surgeon’s guidance and progress to normal activities3.
Preserving the abductors and short external rotators, and obtaining excellent acetabular position to ensure
accurate cup placement, greatly reduces the likelihood of a dislocation in a tissue-balanced hip.
Minimally invasive surgery is defined as the least damaging procedure to the surrounding tissue4.
Exposure during surgery is critical for patient safety and allows for reproducible outcomes with every
procedure. By using the intermuscular and internervous plan between the tensor fascia lata and the
sartorius muscle, and by not releasing the short external rotators of the hip, the DAA has shown to benefit
the patients with an earlier return of hip function. This was documented by Nakata with improvement
in mobility and in stability of the hip as early as 3 weeks post operatively3. Several other authors have
documented that both the DAA and MPA THA functional outcomes are very comparable at 3, 6 and 12
months out from surgery. The strength of Nakata study can be viewed as procedures being performed by
a single surgeon, with a history of successful MPA-THA and then changing to DAA-THA, in a consecutive
similar patient population, with a retrospective data comparison. The two groups were equivalent in age,
BMI, hip scores and mobility pre-operatively.
Further studies of the DAA-THA with focus on hip functioning from the first day post-op to six weeks
and beyond surgery are needed. These additional findings will increase individual patient understanding
of the available procedures and recovery expectations. With a more active population undergoing hip
replacement the anterior approach adds benefits to patient safety and return to early recovery.
REFERENCES
Buckwalter JA, Saltzman C, Brown T. The impact of osteoarthritis:
implications for research, Clin Orthop Relat Res 2004;427(Suppl):S6-15.
2 Bhandari M, Jatta JM, et al. Outcomes following the single-incision
anterior approach total hip arthroplasty:a multicenter observational
study. Orthop Clin N Am. Jul 2009;40(3):329-42.
3 Nakata K, Nishikawa M, et al. A clinical comparative study of the direct
anterior with mini-posterior approach. The Journal of Arthroplasty. 2009;
24(5):698-704.
4 Lovell T. Single-incision direct anterior approach for total hip
arthroplasty using a standard operating table. The Journal of
Arthroplasty. 2008;23(7):64-68.
5 Rachbauer F, Kain MS, Leunig M. The history of the anterior approach to
the hip. Orthop Clin N Am. Jul 2009;40(3):311-20.
6 Sugano N, Takao M, Sakai T, et al. The comparison of mini-incision total
hip arthroplasty through an anterior approach and a posterior approach
using navigation. Orthop Clin N Am. 2009;40:365-370.
7 Nogler M, Mayr E, Krismer M, Thaler M. Reduced variability in cup
positioning: the direct anterior surgical approach using navigation.
Acta Orthopaedica, 2008;79(6):789-793.
8 Masonis J, Thompson C, Odum S. Safe and accurate: learning the
direct anterior total hip arthroplasty. Orthopedics. Dec 2008;31(12
Suppl2).
9 Barton C, Kim P. Complications of the direct anterior approach for
total hip arthroplasty. Orthop Clin N Am, 2009;40:371-375.
10 Kennon R, Keggi J, Zatorski L, Keggi KJ., Anterior approach for
total hip arthroplasty: beyond the minimally invasive technique.
The Jour Bone Joint Surgery, 2004; 86-A Suppl 2:91-7.
11 Meneghini RM, Pagnano MW, Trousdale RT, et al. Muscle damage
during MIS total hip arthroplasty. Clin Orthop Relat Res. 2006
Dec;453:293-8.
12 Mast N, Munoz M, Matta J. Simultaneous bilateral supine anterior
approach total hip arthroplasty: evaluation of early complications
and short-term rehabilitation. Orthop Clin N Am. 2009 Jul:40(3):3566.13 Lewinnek GE, Lewis JL, Tarr R, et al. Dislocations after total
hip-replacement arthroplasties. J Bone Joint Surg 1978;60A:217.
Clinical Pearl
A common intra-operative test to rule
out a periprosthetic joint infection is a frozen
section. The procedure involves sending intraoperative tissue samples to the lab where the
tissue is rapidly frozen, sliced into sections,
and microscopically analyzed. A pathologist
can quickly review the slides and determine if
inflammatory markers are present. Biopsied
material that contains more than 5-10 WBC’s per
high power field (40X) is suggestive of infection.
JOPA 31
There is a distinction between one qualified PA and another.
It’s called a CAQ.
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NCCPA’s Certificate of Added Qualifications Signals
PAs’ ExpertiseTo Employers and Patients
PAs committed to specializing in orthopaedic surgery are among those in only seven specialties
with the opportunity to earn a Certificate of Added Qualifications (CAQ), administered by the
National Commission on Certification of Physician Assistants (NCCPA).
Earning the CAQ in Orthopaedic Surgery allows PAs to document their specialty-focused
experience, CME, knowledge and skills. This credential signals their commitment to the specialty
and is a career milestone that can garner recognition.
“A CAQ validates a PA’s higher level of medical practice, ability, training, and experience,” says
Adam Mays, PA-C, an Orthopaedic Surgery CAQ recipient. “Broadening our scope of practice
within our respective specialties is a duty we should honorably pursue to offer the highest level of
consultation possible to our patients. From a quality of care standpoint, a CAQ brings the PA one step
closer to objectively demonstrating that PAs achieve quality outcomes.”
Recently, more than 200 CAQ recipients responded to an NCCPA survey. Those who were seeking
benefits in the following four areas reported these tangible results:
• Role expansion: For those wanting a new job, over 75% have found one or anticipate finding
one; over 40% successfully sought a promotion; and 60% achieved or expect increased
responsibilities or expansion of clinical privileges.
• Remuneration: For those who sought financial reward, over half have been granted or
anticipate a pay increase, and almost 1/3 received a one-time cash bonus.
• Reimbursements: Over 75% found the CAQ useful in documenting qualifications required
for external accreditation or evaluation (i.e., Joint Commission), and over 1/3 achieved or
anticipated a broadening of their eligibility for reimbursement.
• Recognition: Almost 75% have received greater recognition or regard from physicians or other
health care professionals, with 2/3 reporting greater respect or acceptance from patients.
Mark Wright, PA-C, one of the first PAs to earn a CAQ in Orthopaedic Surgery in 2011, has
experienced these results first hand. “I have been promoted, given higher pay and more
responsibility since earning a CAQ.”
The CAQ exam consists of 120 multiple-choice questions related to orthopaedic surgery. Even for
those PAs in a subspecialty, the CAQ can mean job flexibility and security.
Adds Wright: “As an employer hiring PAs who would you prefer--someone who took the exam or not?
Employers want people with initiative, and earning the CAQ shows initiative.”
According to data reported to NCCPA, the number of PAs working in orthopaedic surgery is
estimated to exceed 8800. Many of these certified PAs have a head start on their way to attaining
a CAQ because they have completed the experience requirement of 4000 hours in the specialty,
the equivalent of two years of full-time practice.
In addition to experience, there are three other requirements to earn the CAQ:
• 150 credits of Category 1 CME focused on orthopaedic surgery within six years of registering
for the program. (The same credits may be used to maintain the PA-C credential.)
• Attestation from a supervising physician in the specialty that the PA has performed or
understands how to perform the relevant procedures and patient management
• Passing the Orthopaedic Surgery CAQ Exam (offered nationwide in September).
For more information and to register for the CAQ program,
visit http://www.nccpa.net/Orthopaedicsurgery.
JOPA 33
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